Payment Integrity Analyst II - DRG Auditor
About The Position
The Payment Integrity Analyst is responsible for accurately reviewing pre and post pay claim audits based on client, policy, industry standards and/or CMS guidelines. This is a remote position. ESSENTIAL FUNCTIONS AND RESPONSIBILITIES: Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication. Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits. Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits. Utilize applicable tools and resources to complete internal audits and/or appeals. Timely completion of internal audits and/or appeals. Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings Additional duties as assigned. KNOWLEDGE & SKILLS: Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits Strong understanding of healthcare revenue cycle and claims reimbursement Proficient in Microsoft Office including Pivot Tables and Database Management Comfortable interfacing with clients and the C-Suite Demonstrate ability to manage multiple projects, set priorities and adhere to committed schedule Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative Excellent written and verbal communication skills Proven track record of delivering concrete results in strategic projects/programs Strong analytical and modeling ability and distilling data into actionable results Superb attention to detail and ability to deliver results in a fast paced and dynamic environment
Requirements
- Must maintain a current LPN, LVN and/or RN licensure
- Previous experience in one or more of the following areas required: Medical bill auditing
- Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics
- Knowledge of worker's compensation claims process
- Prospective, concurrent and retrospective utilization review
- 1+ years healthcare revenue cycle
- 1+ years of relevant experience or equivalent combination of education and work experience
- 1+ years hospital bill audit
- Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format
- Strong understanding of claims processing, ICD-10 Coding, DRG Validation, Coordination of Benefits
- Strong understanding of healthcare revenue cycle and claims reimbursement
- Proficient in Microsoft Office including Pivot Tables and Database Management
- Comfortable interfacing with clients and the C-Suite
- Demonstrate ability to manage multiple projects, set priorities and adhere to committed schedule
- Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
- Excellent written and verbal communication skills
- Proven track record of delivering concrete results in strategic projects/programs
- Strong analytical and modeling ability and distilling data into actionable results
- Superb attention to detail and ability to deliver results in a fast paced and dynamic environment
Nice To Haves
- Preferred experience with health insurance denials and/or appeals, payer audits, or vendor audits
- Bachelor's degree in healthcare or related field preferred
Responsibilities
- Reviews, analyzes, and completes internal audits and/or appeals in accordance with client policy, CMS guidelines and industry standards in clear and professional written communication.
- Ability to use clinical judgement and analytical skills to appropriately review documentation submitted for claim audits.
- Utilize clinical judgement to appropriately interpret and apply client policies along with CMS guidelines as it relates to reviews done by CERIS such as itemized bill, DRG and/or specialty audits.
- Utilize applicable tools and resources to complete internal audits and/or appeals.
- Timely completion of internal audits and/or appeals.
- Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings
- Additional duties as assigned.
Benefits
- Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
